REPUBLIC OF THE PHILIPPINES)

PASIG CITY ) S.S.

AFFIDAVIT

I, ________________________________ of legal age, single and residing

at_____________________________________, under oath hereby depose and state:

1. I was issued a _______________________

2. I inadvertently misplaced the said ___________________ and it could no

longer be found despite my diligent efforts to locate it and is therefore
deemed lost.

3. I am executing this affidavit to attest to the truth of the foregoing and in

support of my application for the issuance of a replacement of my new
_______________________.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ________

day of ______________ at ________________.

_______________________________

SUBSCRIBED AND SWORN to before me this _________ day of

______________ 2023, affiant exhibiting to me her Tax Identification No.
____________________..

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2023.